Breath-Holding Spells in Children

Breath-holding spells are an involuntary reflex that commonly occurs among children, especially those aged under six years. They occur in around 5% of otherwise healthy children. They are most common during the child’s second year of life and are more likely to affect children who have a family history of them.

Breath-holding spells usually occur as a response to the following:

Fear

Frustration or upset

Pain

Traumatic event or accident

Confrontation

The underlying mechanism of breath holding is not fully understood, but tends to involve a slowing of the child’s heart rate and irregular breathing patterns. Although these spells can be extremely distressing for those observing them, they are not usually caused by an underlying health issue, cannot harm the child and pose no serious health risks. A child usually resumes normal breathing within one minute. Often, the spells can be predicted and even prevented from occurring once the factors that trigger them have been identified.

Signs and Symptoms

There are two main types of breath holding and the signs and symptoms differ in terms of causes and characteristics. The two forms of this condition are described below.

Cyanotic breath-holding spells or “blue spells”

Cyanotic breath holding is the most common form. This may occur when a child has hurt themselves or become frustrated by an upsetting event such as being scolded or disciplined. Typically, the child cries or screams and then stops breathing. The skin then begins to turn blue, particularly around the lips, which is caused by a shortage of oxygen. The child then becomes unconscious. After a few seconds, normal breathing, normal skin color, and consciousness return. Parents who have witnessed these spells usually learn to identify and avoid the situations that can trigger them, which is the best way to prevent them.

Pallid breath-holding spells or “pale spells”

This is the less common form of breath holding. Pallid breath holding may occur in children as a response to an injury, sudden fright, or being startled by someone coming up behind them, for example. These spells are therefore more difficult to predict.

The heart rate slows significantly, which causes the child to stop breathing. The skin turns very pale and the child loses consciousness. The child may have a seizure after a prolonged spell, but this is rare. These seizures do not cause any long-term damage or increase the risk of the child developing a seizure disorder. The heart beats very slowly throughout the spell and then speeds up once it has passed, at which point normal breathing and consciousness return.

Voluntary Breath Holding

Voluntary breath holding is easy to distinguish from unintentional, involuntary breath-holding spells. Children who choose to hold their breath do not lose consciousness and eventually start to breathe again once they get what they want or if they become uncomfortable with holding their breath.

Management

During a breath-holding spell, the child should be laid on their side and watched. The child should be put in a safe place where they cannot fall or hurt themselves. Any objects surrounding the child should be removed to minimize the risk of injury.Once the child has started to recover their breathing, people surrounding them should act as usual and refrain from rewarding, punishing, or making a fuss of the child. If parents have learned to identify situations that trigger a spell, distracting the child with another activity can sometimes help to prevent the onset of a spell.

When to See the Doctor

Medical care should be sought in cases of a first breath-holding spell, since they can sometimes indicate another health issue. Once this possibility is ruled out, a doctor can help parents establish potential trigger factors for the spells and therefore ways of preventing them in the future. They can also advise parents about how to manage spells if they do occur again.

Parents should also visit a doctor if either of the following apply:

The spells are very frequent (more than once a day). This may still be normal, but a child experiencing frequent spells should be checked by a doctor.

If a child has a prolonged seizure (more than a couple of minutes) and seems drowsy or confused for hours afterwards.

Prognosis

Breath-holding spells disappear by time a child turns 4 years in around 50% of cases and by the time they are aged 8 in 83% of cases. In a small percentage of cases, children continue to experience these spells as they grow older and into adulthood.

Preterm birth is a dangerous condition that often goes undiagnosed. Fetal fibronectin (fFN) is a biomarker for preterm labor, but testing for fFN is widely underused. We explore this issue with Dr. Michael S. Ruma, a maternal-fetal specialist from the Perinatal Associates of New Mexico.

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